In a previous article Collaboration between Clinicians and Laboratories Critical to New Healthcare Model I discussed the need for laboratorians to work directly with clinicians to develop appropriate protocols  and decision support tools for not only ordering test but also in providing interpretation of the results.

There are many examples and existing tools being used today that clinicians should be demanding from their laboratories to assist in ordering and interpreting laboratory results. Some of those tools were detailed in the post Tools to Help Physicians in ordering and interpreting Laboratory Tests, Part 1. Today I will discuss a few more of these common tools.

Algorithms and Cascade Testing

An algorithm may be viewed as a road map for appropriate test ordering in the work-up of a suspected condition.  The use of an algorithm enables appropriate sequencing of tests with screening tests ordered before more expensive and extensive testing.  In cascade testing, the informatics system allows the ordering of an algorithm and enables the laboratory to perform the initial testing and, following the algorithm, automatically stop testing or order additional pre-approved appropriate testing.  Mayo Medical Laboratory reports that using the Celiac Disease algorithm, the average weighted price for orders was $67.60 vs. $515 if the total package were to be ordered.

Reduced Duplicative Testing

Even with the increasing availability of sharing of medical information through an EMR, duplicative testing can become an issue with patients seeing several different providers within the same time frame.  The Cleveland Clinic recently reported a program, developed by a group of physicians representing a broad spectrum of providers, where the parameters of 13 tests were set in LIS and if the test was ordered more frequently than approved by the committee, a pop up would appear with the date, time and the result of the most recent test.  Proper authority was required to over-ride the pop-up and order the test again. Ultimately, they were able to incorporate 1259 different analytes into this scheme.

As we move from volume to value this is a potentially useful tool in a practice where there is broad connectivity with multiple physicians.  The other side of the coin is the use of informatics to alert the physician to underutilized studies that might be appropriate given a patient’s history and prior testing.  There has not been much published on this topic but certainly prognostic tumor markers at set intervals, diabetic follow up, GC/Chlamydia screening all lend themselves to alerts to improve patient care.

Pop-ups & Hot Links

Pop-ups can be a useful tool in certain circumstances as noted in the Cleveland Clinic experience.  However, they must be used judiciously to avoid pop-up fatigue. Particularly, pop-ups can be useful when a test requires pre-authorization and in circumstances where a test may have potentially high out-of-pocket costs for the patient.

I have found hot links to be very helpful for the clinicians ordering tests to obtain more information about the usefulness, interpretive information, algorithm composition, components of a bundle order, costs to patient etc. These hot links have proven to be time saving and in the long run can be cost effective.

Integration of data

This is a higher level of informatics assistance in test ordering.  Data integration is the ability to electronically use all available data from the medical record, be it imaging studies, differential diagnoses, previous clinical findings, and prior laboratory studies and integrate that information into potential actionable items to assist in patient care.

Interpretative Reporting

If radiologists and surgical pathologists can provide interpretative reporting, why is the clinical laboratory not doing likewise when multiple inter-related studies have been ordered and the ultimate interpretation requires integration of information and specialized knowledge?  Vanderbilt University began providing interpretations with sophisticated coagulation studies and gradually spread this to other areas of the lab.  In some instances informatics systems can be programmed to provide interpretative information but in other circumstances, coagulation studies being a prime example, human intervention to provide interpretative information is needed.

Point-of-Care Support from Reference Laboratories

Clinicians should also demand support from the reference laboratory for POC assistance. The reference laboratory is not just a partner in referred test ordering, but also should provide advice on technology and instrumentation for POC.  If an organization has multiple sites where POC is being performed, the reference laboratory should coordinate with all the POC facilities to ensure all sites performing the same POC tests are using the same technology.  This ensures that there is harmonization of results being fed into the EMR by the POC laboratories.  The reference laboratory can then also furnish assistance in providing to each of the facilities educational material to be certain the individuals performing the tests are trained and competent.

Conclusion

These tools are simple and effective ways that the laboratory can collaborate with clinicians to ensure appropriate decisions are made in ordering tests and resources are optimized to eliminate unnecessary costs.  The clinical laboratory is positioned the play a pivotal role in the transformation of medicine towards patient-centeredness and care coordination for each individual. As the industry places emphasis on moving from volume to value reimbursement, it becomes incumbent upon the laboratory to work with clinicians and ensure quality care for every patient while reducing redundancy.